Heart failure has been diagnosed in 5% of veterans eligible for VA health benefits, and it has an annual mortality of 13% . For patients with advanced disease, access to multi-disciplinary programs offering advanced therapies results in improvements in the quality of life and reductions in morbidity, mortality and the cost of medical care . For several years, such a program has been in place at the VA Salt Lake City Health Care System, a nationally-designated VA heart transplant center and the VISN 19-designated center for advanced anti-arrhythmic therapies.
Geography has been shown to reduce access to advanced medical care [3-5]. VISN 19 covers an especially broad geographic area, and outlying VA Health Care Facilities (Fort Harrison, MT; Sheridan, WY; Cheyenne, WY; and Grand Junction, CO) provide a large proportion of the medical care to veterans in this VISN  (figure 1). Advanced heart failure is likely to be as prevalent among patients at these centers as in patients seen at the VA Salt Lake City HCS. This raises the question of whether outcomes can be improved through an increase in the access of veterans at outlying facilities to an advanced heart failure program.
1. To implement outreach activities at outlying VA Health Care Facilities in VISN
19 that will include educational sessions, consultations and the
establishment of direct referral lines to the VA Salt Lake City Advanced Heart
2. To quantify the consequent increase in referrals to the VA Salt Lake City
Advanced Heart Failure Program.
3. To quantify changes in the application of evidence-based therapies for heart
failure, including initiation and/or up-titration of therapies of proven value
and discontinuation of unhelpful and potentially harmful therapies, in referred
4. To quantify the predicted impact of these changes on survival.
1. To implement outreach activities at outlying VA Health Care Facilities in VISN 19 that will include educational sessions, consultations and the establishment of direct referral lines to the VA Salt Lake City Advanced Heart Failure Program: A cardiologist and a nurse practitioner from the VA Salt Lake City Advanced Heart Failure Program will visit two of the four outlying VA Health Care Facilities - Grand Junction, CO and Fort Harrison, MT - twice during the six-month period. No visits will be made to the Sheridan, WY and Cheyenne, WY facilities, which will serve as a control group. Visits will include didactic sessions, case-oriented discussions and distribution of teaching materials for providers and patients. Contact information for direct interaction with the Advanced Heart Failure Program team will be provided.
2. To quantify the consequent increase in referrals to the VA Salt Lake City Advanced Heart Failure Program: Upon completion of outreach efforts, the number of referrals to the Advanced Heart Failure Program from each outlying health care facility - including actual patient visits and 'virtual' referrals by telephone and email consultation - will be compared to the number of referrals in the corresponding six-month period in the prior year. Changes in referral rates from the facilities visited and from the 'control facilities will be compared..
3. To quantify changes in the application of evidence-based therapies for heart failure, including initiation and/or up-titration of therapies of proven value and discontinuation of unhelpful and potentially harmful therapies, in referred patients: Specific changes to be quantified include initiation or up-titration of -adrenergic receptor antagonists, angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, aldosterone receptor antagonists, hydralazine and nitrates. We will also quantify discontinuation of non-steroidal anti-inflammatory agents, first-generation calcium channel blockers and other antihypertensive agents whose use in heart failure is not supported by published evidence.
4. To quantify the predicted impact of these changes on survival: The impact of changes in therapy in patients will be analyzed using the Seattle Heart Failure Model, through which predicted survival benefits of newly implemented therapies can be quantified . (This model can be applied only to newly implemented therapies and not to up-titration of existing therapies.)
Personnel and resources
The Advanced Heart Failure Program at the VA Salt Lake City Health Care System is comprised of Drs Josef Stehlik and Matthew Movsesian, the co-principal investigators on this proposal, and NP's Mary Hagan and Robin Waxman. These providers will visit the outlying health care facilities and carry out educational activities and consultations. Ms Hagan and Ms Waxman will coordinate referrals, see patients in clinic with Drs Stehlik and Movsesian and carry out the data-collection aspects of the proposal. The creation of a new staff support position for the Advanced Heart Failure Program has made it possible for Ms Hagan and Ms Waxman to take on these additional responsibilities, which have been given a high priority by the VA Salt Lake City Health Care System administration.
1. The number of referrals for heart failure from the facilities visited did not increase as a result of our outreach efforts - 6 before intervention, 5 after the intervention. The overall number of Cardiology referrals from the two hospitals where our intervention was implemented did increase (14 to 23), however the number of Cardiology referrals also increased in the control group of two hospitals without such intervention (3 to 21) -table 1.
2. In both of the visited hospitals, we were told that the frequent unavailability of telemetry inpatient beds at our institution is a major deterrent to pursuing a transfer of a patient to the VA Salt Lake City facility. As a result, even in the case of patients with advanced heart failure, the hospitals opt to transfer patients to an alternate facility where bed availability does not appear to be a problem. Referral to Salt Lake City is therefore often limited to patients who are to be evaluated for heart transplantation, a small subgroup of patients with advanced heart failure, or to those expressing a strong preference to be seen in Salt Lake City.
3. The interaction during didactic and case-based presentations revealed that the clinicians at referring centers have a good understanding of evidence-based therapies for patients with advanced systolic heart failure. In turn, they expressed interest in further education in less common forms of heart failure, such as diastolic heart failure and right heart failure resulting from pulmonary hypertension.
Table 1. Number of referrals from hospitals with and without outreach intervention. Data for 9 months before and 9 months after the intervention are compared
Referrals in 9 months before intervention:
Heart Failure: 6
Heart Failure: 0
Referrals in 9 months after intervention:
Heart Failure: 5
Heart Failure: 4
This was a pilot study. This study did not give us an indication that our intervention would result in a higher number of veterans referred to the Advanced Heart Failure Program in Salt Lake City. There might be other approaches that may achieve this goal.
- Kfoury AG, Hammond ME, Snow GL, Stehlik J, Reid BB, Long JW, Gilbert EM, Bader FM, Bull DA, Renlund DG. Early screening for antibody-mediated rejection in heart transplant recipients. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2007 Dec 1; 26(12):1264-9.
- Rasmusson KD, Stehlik J, Brown RN, Renlund DG, Wagoner LE, Torre-Amione G, Folsom JW, Silber DH, Kirklin JK, Cardiac Transplant Research Database Group. Long-term outcomes of cardiac transplantation for peri-partum cardiomyopathy: a multiinstitutional analysis. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation. 2007 Nov 1; 26(11):1097-104.
- Stehlik. Advanced Heart Failure Therapies: Current Evidence, future Directions; Get with Guidelines. Poster session presented at: American Heart Association Annual Scientific Sessions; 2008 Nov 8; New Orleans, LA.
- Kfoury, Hammond, Snow, Stehlik, Fisher, Reid, Long, Gilbert, Bader, Renlund. Antibody-Mediated Rejection in Heart Transplantation: More than present-or-absent. Presented at: International Society for Heart & Lung Transplantation Annual Meeting; 2008 Feb 1; Boston, MA.
- Stehlik, Edwards, Taylor. Different Immunosuppressive Approaches, similar outcomes. Presented at: International Society for Heart & Lung Transplantation Annual Meeting; 2008 Feb 1; Boston, MA.
- Stehlik, Feldman, Brown, VanBakel, Russell, Ewald, Hagan, Folsom, Kirklin. impact of Interaction of Donor Characteristics on Post-Transplant Survival. A multi-institutional analysis. Presented at: International Society for Heart & Lung Transplantation Annual Meeting; 2008 Feb 1; Boston, MA.
- Stehlik, Islam, Hurst, Fuller, Delgado, Ellinger, Movsesian, Kfoury, Gilbert, Bader, Fisher, Renlund, Hammond, Bull, Singhal, Eckels. Virtual Crossmatch should be utilized in sensitized patients to improve organ allocation. Paper presented at: International Society for Heart & Lung Transplantation Annual Meeting; 2008 Feb 1; Boston, MA.
- Stehlik. Heart Transplantation Indication; Evaluations of the Organ Donor. Paper presented at: American Society of Transplantation Fellows on Transplantation Medicine Annual Symposium; 2008 Jan 1; Dallas, TX.